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Update: How to Determine Whether to Obtain Prior Authorization for an Off-the-shelf vs Custom Fit Brace or Both Codes

Obtaining a prior authorization for an orthotic brace can be confusing if suppliers are unsure of what type of brace will be provided and billed since the off-the-shelf and custom fit codes are only differentiated by the nature of the final fitting performed at the time of delivery. To solve this confusion, suppliers should obtain a prior authorization for both the off-the-shelf and custom fit braces. Then, after the final fitting, bill for the brace provided based on the type of adjustment that was needed at the final fitting. Medicare will only cover one medically necessary brace. Suppliers may choose to submit multiple codes on one prior authorization request; however, when multiple codes are submitted, each HCPCS will be treated as its own review, and the supplier will obtain a prior authorization decision for each code. To avoid a missed code, suppliers must make sure documentation clearly shows both codes that are intended to be reviewed.